Provider Demographics
NPI:1376361048
Name:PETRASKO, KRISTINA LYNN
Entity type:Individual
Prefix:MRS
First Name:KRISTINA
Middle Name:LYNN
Last Name:PETRASKO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1147 W RIDGEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54914-1464
Mailing Address - Country:US
Mailing Address - Phone:920-213-4653
Mailing Address - Fax:
Practice Address - Street 1:976 AMERICAN DR STE 14
Practice Address - Street 2:
Practice Address - City:NEENAH
Practice Address - State:WI
Practice Address - Zip Code:54956-1933
Practice Address - Country:US
Practice Address - Phone:920-215-3401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-01
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional